Comments of Management models

What innovative strategies could fill the gaps?

Views on innovation in chronic disease management models vary between two extremes, from the most optimistic forecasts as to their impact (78) (reduction in mortality and resource utilization, with net savings to the system) to the more skeptical, questioning whether they are worthwhile (79).

As noted above, there is evidence supporting mostly the effectiveness and efficiency of individual interventions (80-87), but there is still a lack of standardization in almost all aspects of such interventions. Some prestigious organizations have proposed the use of a standard taxonomy (88), and there are projects aiming to enrich this with the emphasis on multiple conditions (89).

Cooperation, especially across institutional, national and cultural boundaries, is essential to avoid overlapping efforts, to encourage a public debate, and to promote effective policy change.  New technologies could play an important role, not only to facilitate meetings and communication across long distances, but also to promote the design and implementation of multi-centric studies using standardized measurements.

Although the context for transformative efforts is highly favorable, bringing about large scale shifts in the health system to meet the challenges posed by complex chronic diseases will demand planning, change management and concerted efforts at all levels within the health system.

For any meaningful change to occur, policy makers, funders and health care managers would need to view the sector with new eyes and understand that the playing field now involves complex adaptive systems that have rendered traditional solutions irrelevant. Health professionals and patients cannot be considered any longer as «standardizable» and predictable components of a depersonalized system.

The complexity of the desired system change can be better illustrated by means of an example. Studies indicate that 76% of hospital readmissions are avoidable (90) within 30 days of discharge. This represents 13% of admissions to a modern-day hospital, a high proportion of which are complex chronic «frequent flyer» patients (Chapter 3).

The evidence indicates that this situation could be rectified through a reduction in complication rates during hospital stays, improvement of communication in the hospital discharge process, closer monitoring and active participation of the patients at home, and better communication and cooperation between hospital and primary care following discharge. These outcomes could be achieved by means of optimal continuity of care resulting from integrated care processes that guarantee that patients remain engaged and monitored following discharge, and that managers and professionals work seamlessly across the hospital-community divide (Chapter 6). Unfortunately, most systems around the world continue to operate under highly centralized policies and procedures that nurture a traditional acute care model in which hospitals rule over a fragmented ecosystem of services.

With the impending pandemic of chronic diseases, and with the new challenges created by complex cases, it is imperative to muster the levels of leadership and commitment to change, and to abandon the usual linear process of planned change that pervades most systems (Figure 5).

Figure 5. The linear process of planned change. Adapted from "Planned Change"  (91)




Times have changed. This highly prevalent planning approach reflects an excessively simplistic vision of the way organizations work today. Although it is applied with the best of intentions in an attempt to reorganize the sector on the basis of hierarchy and linear top-down planning, it is outdated, as it reflects the conditions of an era of management derived from the industrial age, with central managers at an organization defining strategy, creating structures and systems to influence what have been called «organization men» (92).

It is a philosophy that expected a high degree of conformism from its human resources, and this has for some time not corresponded to the situation in the health sector, where health professionals and local administrators are increasingly alienated and disconnected from the central management and policy-making engines of the system.

Nowadays, change will only be possible through  local leadership and enthusiastic participation of health professionals, administrators and the public within the network of care. This calls also for greater sophistication in the management/planning of the system to enable professionals and users to play a much more strategic role in the development and refinement of models that match the needs of people living with multiple chronic diseases. This is clearly a complex cultural change for which there is no magic wand.

As with any other complex system, progressive steps will be needed to re-build the system from the bottom up, while drawing on the intellectual capital of front line professionals, administrators, patients and their loved ones. In fact, it has been shown that the most substantial and sustained changes have occurred at those organizations which allow for bottom-up change instigated by frontline users, professionals and managers (93).

As suggested above, policy-makers must devote greater efforts to enabling those working in different parts of the organization (primary and hospital care in particular) to create new ways of working together and to generate communities of practice that spur organizational change. The idea is to promote entrepreneurship among professionals and local administrators rather than expecting them to implement the scripts designed
by those «high up».

This more decentralized form of leadership does not mean sacrificing the benefits achieved over recent years through direct, centralized management. Nor does it mean a return to the past, to a system in which professionals are not accountable and do not need to report back. In a decentralized system, central policy-makers and managers should act and be perceived as motivators, promoters of interrelationships at all levels and network facilitators. One of their main roles in a modern system should be the reinforcement of incentives to encourage local teams of health professionals, administrators and members of the public to experiment with improvements of their own device, facilitating the availability of resources, analyzing and comparing results and disseminating lessons learnt across other teams within the network.

Another key role for central policy makers and managers could be the creation of mechanisms to support management training and the promotion of local leadership. Local managers need to know, among other aspects, how to motivate teams, build networks, involve the community in change management, and harmonize local initiatives with the general strategies pursued by the organization at large. In the Basque Country (Spain), for example, an organization has been created to fulfill this role. This organization, known as O+Berri, has as one of its main functions the promotion of best practice communities throughout the organization. In this regard, the agency also promotes connectivity among different best practice communities, while assisting sector managers in analyzing trends to optimize their strategies for the dissemination of innovations and policies throughout the system.

The strength of this more decentralized form of leadership and administration lies in taking advantage of the intellectual capacity of the network and abandoning the false illusion that it is possible to devise one single operational model for an entire region or country. Within such a system, the differences that exist across organizations should be viewed as a strength, not as a weakness, with leaders at all levels relentlessly pursuing innovative ways to facilitate and enable improvements in contexts that are more receptive to such changes thanks to their collective effort and commitment.

In addition, we need greater investment and an active quest for new ideas to be incorporated within the models, with bolder forms of evaluation allowing for a sharper learning curve (the clinical trial model is perfect in isolating simple effects, but it is of less use in learning from complex experiences). The new forms should include participatory evaluation taking into consideration the perspectives and expectations of professionals
and users. In complex contexts qualitative research techniques may clear the path more effectively than quantitative techniques, which will always be subject to bias in omitting significant aspects for which data are not available.

What is needed is a pioneering spirit in order to go beyond the existing models. Perhaps more radical change is needed (in the sense of dealing with the root) in cultural forms of dealing with the responsibility of individuals as to their health and illness. What is lacking is a clear commitment to the capacity of individuals to acquire knowledge, to
change their conduct and allow them to choose freely.

Existing comments

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La cooperación de los distintos niveles es fundamental, en un problema de la magnitud del que estamos abordando la implicación de todos desde los políticos hasta los profesionales es la única garantía de éxito.

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La cooperación, sin duda, es la clave. Pero no creo que dependa tanto de los profesionales sanitarios más que de ´los gestores del sistema sanitario e incluso voluntades políticas. Y no creo, tal y como se ha dicho aqui, que suponga necesariamente más recursos. 

19/03/2012 Conchi Candela
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Las políticas sanitarias, creo que han virado desde la integración de las profesiones para mejorar la práctica al mandato de lo que ahora se debe hacer. En mi opinión se han vuelto menos democráticas, cuando se alejan de la practica en aras de reducir los costes, llenan de actividades a los y las profesionales, incrementan en descontento, facilitan el desencanto en el trabajo, en definitiva se pierde calidad asistencial. Quizás sea una visisón pesimista, pero es la que por la crisis, creo vivir.

La propuesta de mejorar la práctica, y sobre todo la política que engloba tal práctica, deben de estar presentes quienes desempeñan la labor asistencial: profesionales de distintas categorías y personas afectadas de polipatologías

06/03/2012 Lola Nieto
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Creo que la respuesta la tenemos en gran medida los profesionales. Estamos tratando directamente con los problemas por ello tendríamos que ser capaces de elaborar y evaluar modelos que pudieran asegurar el cuidado integral de los sujetos con enfermedades crónicas. 

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